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  1. Evidence for health differentials
    • Australia
    • U.S. & U.K.
  2. Social & behavioural determinants across the lifecycle
  3. The ‘Inverse Care’ law
  4. Reducing inequalities
  5. Factors influencing preventive care
  6. How to improve access to preventive care in disadvantaged communities?

Equity in health

  • The absence of systematic and potentially remediable differences in one or more aspects of health across populations or population groups defined socially, economically, demographically, or geographically.
    • Nonremedial (can't change): age
    • Remedial: education, income
  • Evidence for health differentials: 17% of burden of disease in Australia attributable to socio economic inequalities (i.e. if you brought the poor to the level of the rich, you'd get rid of 17% of the burden; more than smoking)
  • Between 1992 & 2002, the proportion of excess deaths due to socioeconomic inequality increased for:
    • cardiovascular diseases overall (from 21% to 28%)
    • CHD (from 23% to 32%)
    • stroke (from 16% to 24%)
  • Burden of disease: Disease burden is the impact of a health problem on an area measured by financial cost, mortality, morbidity, or other indicators. It is often quantified in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs), both of which quantify the number of years lost due to disease.

Cardiovascular disease mortality by quintile of socioeconomic disadvantage, 25–74 year olds, 2002 AIHW

  • Gradient: more disadvantaged have higher death rate than least disadvantaged.
    • Also males die at a higher rate

Diabetes-related deaths by quintile of socioeconomic disadvantage (SEIFA), 2001–2003 (AIHW)

Trends over time: Standardised mortality ratios in males 20-59 in manual & non-manual occupations: 1966-70 to 1996-2000

  • X-axis is the ratio of death risk in manual worker vs non-manual workers
  • Since the 60s, manual work has changed to involve much less physical activity, so rates of lifestyle disease have increased
  • Also, there has been a shift in diet: higher rates of fast food recently
  • Note that the overall rate of mortality has improved, but it has improved to a greater extent in the non-manual people

Ischaemic heart disease among males aged 20–59 in manual & non-manual occupations, age-standardised mortality rates: 1966-2001

  • While everyone's mortality increased, the gap became greater
    • Changes in lifestyle patterns occur more rapidly in one group over another (e.g. nonmanual are faster at quitting smoking, manual are faster at eating fast food)

CHD Mortality by SEIFA (Q1 most disadvantaged)

Social & behavioural determinants across the lifecycle

  • Think about cohorts of people: baby boomers were in their 30s during the '80s -- what were they doing then?
    • Think about each of these risk factors over time, not just what's happening now

Percentage of females aged 15–24 years who were classified as regular smokers, by IRSD quintile, 1989–90, 1995 & 2001 AIHW

  • Over 1990-2000, the smoking rate in the most advantaged group has decreased. In the most disadvantaged group, the smoking rate has stayed about the same. Our public health policies have a differential impact on different economic echelons of society
    • This has produced a social gradient
    • Why is there a social gradient?
      • Way in which messages are delivered - geared towards the more-educated
      • More educated people have the capacity to adapt
      • Unequal access to information and healthcare
  • Similar story in adding salt to food and in hypertension
  • Most dramatic example of this social gradient is obesity
    • More marked differential in women
    • Diet is much more complicated than just smoking - not just about "97% fat free", but about getting the right composition. Therefore lower SES affected more.

Percentage of females aged 25–64 years who reported experiencing diabetes as a long-term condition, by IRSD quintile, 1989-90, 1995 & 2001 (AIHW)

  • Directly related to obesity

Obesogenic environment

  • Lack of physical activity, and availability of healthy diet

Protective capacities

  • Good education and health literacy
  • Positive peer pressure
  • Flexible work/ work satisfaction
  • Access to more healthy lifestyle options
  • Positive family diet pattern


  • Poor education & health literacy
  • Peer pressure at work/ social interaction
  • Less control at work – work stress
  • Poor family diet habits
  • Less access to healthy lifestyle options
    • Geographical and economic: fruit and vegetables are more expensive than fast foods.

We might be contributing to this! Inequalities in preventive care: the Inverse Care law

  • Those who need it most are least likely to get it
  • "The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.” Lancet, 1971
  • Dr Julian Tudor Hart, GP in Wales
  • “the 1st doctor to routinely measure every patient’s blood pressure - as a result, reduced premature mortality in high risk patients at his practice by 30%”

Factors influencing preventive care

  • Patient
    • Socioeconomic and cultural influences
    • Cost
    • Health literacy
    • Accessibility
  • Doctor
    • Knowledge
    • Attitudes
    • Time
      • Low SES has lower doctor:patient ratio (more patients)
      • Low SES has more problems (requires more time)
    • Capacity/roles

Addressing lifestyle risk factors in disadvantaged populations

  • Other pressing social issues to address first
  • E.g. domestic violence, teenage mum, etc


  • Health Literacy: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions
    • Need to think about peoples' capacity to take on advice

Level of health literacy and socioeconomic status (AIHW 2010)

  • Health literacy isn't exactly the same as SES, but it's highly correlated
    • There are still patients with low health literacy in high SES

Six signs of limited health literacy (Weiss 2007)

  • Fill in forms incompletely or inaccurately
  • Frequently miss appointments
  • Not follow through with lab tests or referrals
  • Say they are taking their medications but the lab tests or physiological parameters do not change in the expected fashion
  • Unable to name their medications, explain what they are for or tell when they are supposed to take them
  • Say: "I forgot my glasses" or "I’ll read this when I get home"

Disparities in patient- centeredness by health literacy

  • Patients with inadequate health literacy were more likely to report worse communication in the domains of:
    • general clarity (AOR [Adjusted Odds Ratio] 6.29, P<0.01)
    • explanation of condition (AOR 4.85, P=0.03)
    • explanation of processes of care (AOR 2.70, p=0.03) (Schillinger D et al. 2004)
  • Patients with lower health literacy:
    • ask fewer questions of physicians in observed medical encounters (Katz et al. 2006; Beach et al. 2006)
    • are more likely to be perceived by physicians as desiring a less active role (Beach et al. 2006)

What can we do to improve access to preventive care in disadvantaged communities?

  • Reduce cost & other barriers to access (particularly reduce cost as a barrier to preventive care)
  • Develop culturally appropriate services
  • Increase continuity of care (see the same provider; trust + provider figures out they're having trouble understanding)
  • Identification and tailoring of management to health literacy
  • Involve local communities & respond to their needs
  • Provide education to develop patient skills & health literacy
  • Provide outreach services (don't just wait for people to come in)
  • Offer social support through telephone, or home visits

Health Literacy Screening

  • A. How often do you have someone help you read health information materials?
  • 1. Never 2. Occasionally 3. Sometimes 4. Often 5. Always
  • B. How often do you have problems learning about your medical condition because of difficulty understanding health information materials?
  • 1. Never 2. Occasionally 3. Sometimes 4. Often 5. Always
  • C. How confident are you filling in medical forms by


  • 1. Extremely 2. Quite a bit 3. Somewhat 4. A little bit 5. Not at all

Effective communication (DeWalt et al 2010)

  • Prioritise what needs to be discussed to 3-5 key points
  • Draw pictures, use illustrations or demonstrate with models
  • Engage patients to ask questions what questions do you have rather than do you have any questions
  • Confirm patients understand by asked them to explain the key points. If they cannot remember accurately, repeat what you asked them, clarify your information and then ask them to describe in their own words what they are going to do
    • "can you please tell me the main things you've taken from this?"
    • "Teach Back"
  • Follow up with patients

Managing low health literacy - NAVIGATION

  • Appropriate education materials
  • Web and phone support
  • Referral

System change

*Enhancing universal programs:

    • Information system development
    • Service partnerships: Improved availability and affordability of referral services
    • Audit and facilitation of practice improvement
  • Targeted programs for disadvantaged populations - still have a place in the system

  • Australia has a strong universal system - in theory this is accessible to the whole population
    • To fix the problem, we need not only a targeted extra service, but instead have a proportional universalism service - providing more of the universal system to the disadvantaged groups; e.g. providing health cheques through medicare to refugees etc